1. The association between stress and episodes of symptom manifestation of genital herpes: a systematic review of the literature Eamann Breen The Mortimer Market Centre

3. “It is more important to know what kind of person has the disease than what kind of disease the person has”. (Hippocrates)

4. Background Objectives Search strategy Selection criteria Data collection and analysis Main results Limitations of review Conclusions

5. Genital Herpes Pathology Burden of Disease

6. What is stress? Definitions Measurements of stress Causes and triggers Stress and the immune system

8. Aims and Objectives The aim of this study is to investigate systematically the hypothesis that there is a relationship between an increase in stress and recurrent genital herpes, specifically where stress acts as a predictor for repeat episodes of the virus. Whether there is an association between patient psychological stress and recurrent episodes of genital herpes? How reliable are the existing studies? Where is the potential for further research?

9. Definition A Systematic review “is a review of a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant research, and to collect and analyse data from studies that are included in the review."

10. Why undertake a systematic review? Research into what is perceived by patients as stressful and what leads to recurrence has already been undertaken. Additional primary research was rejected with a view to review the work already available. The purpose of this research is to identify information that may not be apparent from individual studies where the effects under investigation may be small, or where there are conflicting findings from different studies.

16. Results Included studies Excluded studies

17. Prospective and retrospective studies Study/DesignSubjectsTimescaleFindingsGradeLevel of evidence (Cassidy, Meadows et al. 1997)N = 116, m= 48, f =68n/aNo relationshipB3 UK, Retrospective (Swanson, Dibble et al. 1995)N = 70, m = 41%, F = 59%n/asupports relationshipB3 US, Retrospective (Swanson and Dibble 1993)N = 252, m = 59, f = 193n/asupports relationshipC4 US, Retrospective (Brooks, Haywood et al. 1993)N = 90, 40 =m, 50 = f, n/asupports relationshipB3 UK, Retrospectivemedian age = 34, range 19 - 60 (Keller, Jadack et al. 1991)N = 60, m =26, f =34, n/aNo relationshipC4 US, Retrospectivemean age 31.7 (S.D =/- 8.1) (Longo and Clum 1989)N = 46, m = 18, f = 28n/asupports relationshipB 3 US, Retrospective (VanderPlate and Kerrick 1985)N = 59, m =16, w = 43.n/aContradictory relationship B3 US, Retrospective (Silver, Auerbach et al. 1986)N = 67, m =32, f = 35, n/asupports relationshipB 3 US, Retrospectivemean age = 33 range 20 - 65 (Bierman 1983)N = 375, m = 202, f = 173n/asupports relationshipC4 US, Retrospective (Cohen, Kemeny et al. 1999)N = 58, all f, 6 monthssupports relationshipB 3 US, Prospectivemean age = 31.8 (S.D +/- 5.8) (Kemeny, Zegans et al. 1987)N = 36 f = 30, m = 6, 6 monthsNo relationshipB3 US, Prospectivemean age 33.4, (SD 9.5, range 18 -69) (Rand, Hoon et al. 1990)N = 64, m = 13, f = 5, 6 monthsNo relationshipB3 US, Prospective mean age =27.9 (S.D +/- 5.7)

18. Intervention Studies StudySubjectsInterventionMeasures (VanderPlate andN = 4, all fBiofeedback, and2 subjects given Electromyographic (EMG) biofeedback, Kerrick 1985) USMuscle relaxation treatment2 subjects given progressive muscle relaxation treatment (PT) Timescale 6 months Results Biofeedback resulted in a 72% and 7% decrease in recurrences, PT resulted in 66% and 100% reduction in recurrences Grade B Level of Evidence 3 Longo, Clum et al. 1998)N = 31 not specified Psychosocial intervention, Profile of Mood States USsocial support, andZung Depression Scale waiting list controlUCLA Loneliness Scale MHLC scales Hassles Scale and Contact Questionnaires. Timescale 6 months Results Perceived stress did not differ among treatment conditions Psychosocial interventions reduced the severity of recurrences Grade B Level of Evidence 3 Burnette, KoehnN = 8, all fProgressive muscle relaxation treatment Questionnaires et al. 1991) USTimescale 6 months Results 5/8 participants reported a significant reduction in recurrence rate Grade B Level of Evidence 3 (Koehn, BurnetteN = 4, all fApplied relaxation skillsDaily diary et al. 1993) USPre and post treatment relaxation evaluations Pre and post treatment relaxation application evaluations Treatment satisfaction EMG measures Timescale 3 months Results All subjects reported post treatment reductions in herpes frequency. Statistically significant for 3/4 participants Grade B Level of Evidence 3

28. Implications of research for practice What advice are we providing? What is the purpose of this advice? Do we have to give ‘positive’advice?